Respiratory therapist's notes shed light on why emergency room patient crashed

Respiratory therapists aren’t physicians or nurses. They’re specialized healthcare professionals who are trained and skilled in respiratory, airway, and cardiopulmonary care. They see patients in hospital emergency rooms (ERs), intensive care units (ICUs), and regular floors.

Perhaps because of this specialized focus, I’ve often found respiratory therapy notes to shed light on what really happened in patient care, when other documentation is suspicious, vague, or missing.

For example, we’ve been working on a case involving a man in his 30s who was treated in a Dallas-area hospital ER for difficult breathing that he’d been experiencing for over a day. Let’s call him Kevin.

In the year before he went to the ER, Kevin had a heart surgery and had battled fluid buildup—called pleural effusions—that interfered with normal breathing. In fact, a handful of times before he went to the ER, he had outpatient thoracentesis procedures where a needle is inserted through his chest wall to evacuate the excess fluid.

On this particular ER visit, the emergency physician ordered x-rays and CT scans that showed that he had a large hydropneumothorax. This is basically a condition where unwanted, excess fluid and air was located between his right lung and his chest wall. The ER physician initially planned to place a chest tube to remedy the problem, but later changed his mind after consulting with the surgeon, who planned to handle the situation the next day.

That was a reasonable plan, until Kevin’s health started deteriorating. When a patient is crashing, waiting until the next day isn’t a viable plan!

Oxygen saturations

One of the clinical vital signs that doctors, nurses, nurse practitioners, physician assistants, and respiratory therapists review is oxygen saturations. Oxygen saturations are measured as a percentage. According to this north Texas hospital’s policy, an oxygen saturation below 90% meant the patient had hypoxemia, or low oxygen level in the blood.

When Kevin walked into the ER, his oxygen saturation was in the high 90s, as he was breathing regular room air. He already had an abnormally high heart rate (tachycardia) and respiratory rate (tachypnea), which were signs that his body was compensating for the breathing difficulty he was experiencing.

Within an hour, his oxygen saturation dipped below 90% and the nursing staff started him on supplemental oxygen delivered by a nasal cannula.

When that didn’t bring Kevin’s oxygen saturation up to a suitable level, nurses started him on a higher level of supplemental oxygen, delivered by a Venturi mask. For a while, that seemed to work, but then Kevin’s oxygen saturation plummeted to the mid-80s, despite him being at the highest level of oxygen support that was available without intubating (inserting a breathing tube into his airway) him.

To skip forward in the story, Kevin was found in his bed unresponsive and sustained a permanent, catastrophic brain injury. When Painter Law Firm was hired to investigate his medical malpractice case, we were surprised by an almost total lack of physician and nursing documentation for the hour or so before his Code Blue event.

Respiratory therapist documentation to the rescue

At deposition, the ER physician and nurse testified that they were in Kevin’s room just minutes before he crashed, and he was sitting up, alert, and talking with them. The doctor said he remembered the in-room monitor showing Kevin’s oxygen saturation was 95% at the time. That wasn’t documented in the vital signs in the medical record, though. Nevertheless, they said Kevin's crash was sudden and unpredictable because he had been just fine moments earlier.

That didn’t make sense, given the clinical information was documented and, of course, the tragic outcome that happened less not even 10 minutes later.

When we looked at what the respiratory therapist documented, the recollections of the ER doctor and nurse were rendered simply not credible.

Minutes before Kevin crashed, a respiratory therapist came to his bedside and documented his oxygen saturation of 88%, which was dangerously low for a patient who’d been struggling to breathe for hours. The respiratory therapist immediately collected a blood sample for arterial blood gas test, per the hospital’s Oxygen Protocol. The laboratory quickly analyzed and reported back critically abnormal results.

The medical experts who reviewed the case said it was unlikely that Kevin would have been able to sit up, talking and alert, with these lab values. Instead, the respiratory therapist’s workup revealed a patient who was at the end of his rope after compensating to avoid a respiratory emergency.

Although the medical record documentation left by the ER doctor and nurse was lacking and their testimony didn’t make much sense, the respiratory therapist’s notes solved the mystery.

If you’ve been seriously injured because of poor hospital or medical care in Texas, contact a top-rated, experienced Texas medical malpractice lawyer for a free strategy session about your potential case. Experienced medical malpractice attorneys know where to look for evidence that sheds light on what really happened in a case.

Article by

Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.